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Mo1024 Endoscopic Cyanoacrylate Injection for the Treatment of Gastric Varices: Experience of a Single US Center
admitted to our ICU with the primary diagnosis of acute GIB were identified. Demographic and clinical characteristics such as age, acuity as measured by APACHE-II severity score, and outcome were obtained from our ICU Project IMPACT database. Diagnosis and endoscopic findings were recorded during review of patient records. Observed mortality was compared to that calculated by the APACHE-II score. Subgroup analysis was performed based on the source of bleeding for patients admitted with variceal bleeding, non-variceal upper GI bleeding, and lower GI bleeding. Two hundred and eighty patients admitted with the primary diagnosis of GIB to our ICU were identified. There were 27 deaths overall for a mortality rate of 9.6%. The average APACHE-II score on admission was 16.0 yielding a predicted mortality rate of 14.2%, significantly higher than our observed mortality rate (p<0.05). Subgroup analysis demonstrated 87 patients admitted with non-variceal upper GI bleeding, with 6 deaths giving a mortality rate of 7.1% in this group. The APACHE-II score in these patients was 15.8 and the predicted mortality rate of 13.9% was significantly higher than our observed mortality rate (p<0.05). Of the 84 patients admitted with non-variceal upper GI bleeding, there were 5 deaths with a mortality rate of 6.4%. The APACHE-II score in these patients was 16.1 and the predicted mortality rate of 14.4% was significantly higher than our observed mortality rate (p<0.05). 58 patients were admitted with variceal bleeding, with 8 deaths and a mortality rate of 13.7%. The APACHE-II score of 15.6 in this group predicted a 13.6% mortality rate, nearly identical to our observed mortality rate (p=NS). While the APACHE-II score remains useful as a measure of disease severity, it overstated the mortality rate for patients admitted to the ICU with acute GIB. The APACHE-II score was accurate in predicting mortality when its use was limited to patients admitted with variceal bleeding. Further studies are necessary to identify prognostic tools for patients admitted to the ICU with acute GIB.
Location of Polyps (p-0.56)
Mo1024 Endoscopic Cyanoacrylate Injection for the Treatment of Gastric Varices: Experience of a Single US Center Murad Abu Rajab, Adrian N. Holm, Rami El-Abiad, Henning Gerke Background:Gastric variceal hemorrhage has a high mortality. Endoscopic cyanoacrylate glue injection (CGI) is successfully used in other countries; however there is limited experience with this method in the US because it is not currently approved by the Food and Drug Administration. Objectives:To assess the safety and efficacy of CGI for treating gastric varices. Patients and Methods:A retrospective chart review of patients who were treated with CGI for gastric varices at a US tertiary care center between 6/2005 and 8/2011. Assessed outcomes included primary hemostasis, recurrent bleeding during hospitalization, rebleeding during follow-up, and complications. Results:Forty-Six patients with gastric varices were included in the study (32 males; mean age 60.6±12.5 years). The underlying cause of gastric varices was cirrhosis in 31, idiopathic portal hypertension in 2, splenic vein thrombosis in 6 and other/unknown etiology in 7 patients.. Concomitant esophageal varices were present in 30 patients. CGI was performed for acute bleeding in 44 patients and for bleeding prophylaxis in 2 patients. CGI was performed with N-butyl-2-cyanoacrylate (n=40), 2-octanyl-cyanoacrylate (n=5) or both (n=1), and N-butyl-2-cyanoacrylate was injected undiluted (n=19), diluted with ethiodized oil (n=21) or both (n=1). The average injected volume during the index endoscopy was 4.5ml±2.7. One (n=4) or more (n=3) additional CGI sessions were performed in 7 patients. Actively bleeding gastric varices during index endoscopy were found in 7/46 patients (15%) and initial hemostasis was achieved in all. Early rebleeding from gastric varices during hospitalization occurred in one patient (2%). Hemostasis was achieved with repeat CGI but the patient died during hospitalization from sepsis. Immediate complications of CGI included ischemic stroke in 2 patients (4%) without residual deficit on follow up, and asymptomatic portal vein cyanoacrylate emboli in one patient (2%). Thirty-three patients had a median follow up beyond initial hospitalization of 14 months (range 1-73). Additional treatments in these patients included esophageal variceal banding in 18, TIPS in 2, splenectomy in 2 and splenic artery embolization in one. In 30/33 (91%) patients no gastric variceal bleeding occurred during follow up. Three patients had rebleeding from gastric varices that was successfully treated with CGI. Four patients had transient mucosal bleeding from the cyanoacrylate injection site despite fully obliterated gastric varices. No intervention was necessary. Three patients had bleeding from esophageal varices treated with band ligation. Conclusion: Endoscopic treatment of bleeding gastric varices using cyanoacrylate glue injection is effective. Serious complications are infrequent. Objectives for future research should include means to further reduce the risk of embolic events.
Mo1022 PEG-3350 for Colon Preparation in Children: Head to Head Comparison Between 2 and 4 Days Protocols Rotem Elitsur, Lisa Butcher, Vicki A. Lund, Yoram Elitsur Preparation of the colon for colonoscopy in children is a difficult task due to a poor compliance. In a previous study we reported an adequate colon preparation in >92% of children using PEG-3350 protocol for 4 days (Safder 2008). In recent publication, PEG3350 protocol for 2 days reached comparable results (Phatak 2011). Aim: To compared between 2 days and 4 days colon preparation protocols. Methods: Children scheduled for colonoscopy for various medical reasons were prospectively and randomly assigned for the 2 different protocols. Protocol A included 4 days PEG-3350 (1.5g/Kg) treatment, and Protocol B included 2 days PEG-3350 (2.0g/Kg) treatment with a daily 5 mg tablet of Bisacodyl. In both protocols, the patients filled a questionnaire that included the number of stools/day, consistency of stools/day and side effects (n/v, abdominal pain). Colon preparation was graded from 1 to 5 (1- unprepared, 5- excellent/crystal clear) as previously described (Safder 2008). Grade ≥4 was defined as an adequate colon preparation. At the end of the procedure, the colon preparation was independently assessed and graded by the endoscopy nurse and the physician. Results: A total of 54 pts participated of whom 31 pts included in protocol A and 23 pts in protocol B. Seven children violated the protocol (violation of instructions, dose of PEG-3350, etc.), and were excluded from final analysis. Overall, in both protocols, a similar rate of adequate colon preparation (≥4) was achieved. Side effects (Abd. pain, V) were minimal and comparable in both groups. An excellent agreement in colon grading was achieved between the physician and the endoscopy nurse (Pearson correlation >0.95). Results are described in Table 1. Conclusion: Bowel preparation with PEG-3350 for 2 days is as good as for 4 days protocol. Two days protocol has the advantage of being shorter and easier for children. Colon preparation and protocols
Mo1025 Risk of Perforation Following Endoscopic Colorectal Stenting is Associated With use of Bevacizumab Glen A. Doherty, Ciaran Judge, Blathnaid Nolan, Dara Kavanagh, Diarmuid P. O'Donoghue, John Hyland, Des C. Winter, Hugh Mulcahy Background. Endoscopic colorectal stenting is considered an effective means of relieving malignant colorectal obstruction, either as part of a palliative care pathway or as a bridge to definitive surgical therapy. Concerns have recently been raised about the safety of colorectal stenting, with high rates of perforation reported in some clinical trials. Aims: To assess the safety and efficacy of endoscopic stenting for neoplastic colonic obstruction. Methods. Patients assessed by endoscopy with a view to colorectal stenting at a single centre were identified by searches of electronic radiology and endoscopy reporting databases. Electronic and clinical records were reviewed and cross-referenced with a prospectively maintained database of patients with colorectal cancer. Results. 112 procedures were performed in 102 patients with a view to stent insertion, with a decision made not to insert a stent in 17 cases (most due to insufficient luminal narrowing). 90 stents were successfully deployed in 95 procedures where there was intent to place a stent (technical success rate 95%). 67 stents were placed with palliative intent and 23 stents as a bridge to subsequent surgery. In the palliative stenting group surgery was avoided in 68% with median interval to death or last follow up of 6.9 months (IQR 2.1-10.5 months). 10 patients required repeat stenting at a median interval of 162 days (IQR 109-206 days). Clinical perforation subsequent to stent placement was described in 9/90 procedures (perforation rate 10%) with the rate of perforation higher in patients who received the monclonal antibody to VEGF bevacizumab; 5/31(16.1%) in
* At the last day of protocol. ** Grade ≥4.0 is adequate colon preparation. Mo1023 Evaluation of the APACHE-II Score in Predicting Mortality in Patients Admitted to the ICU With Acute GI Bleeding Fedele DePalma, Patricia Henry, Philip Elbaum, David Gerber Several scores have been designed to triage patients with acute gastrointestinal bleeding such as the Glasgow-Blatchford Score and Rockall Risk Scoring System. No scoring system has been developed to estimate the mortality of patients with acute gastrointestinal bleeding (GIB) admitted to the intensive care unit (ICU). The APACHE-II score has been used for over 25 years to provide a general measure of severity of disease for patients admitted to the ICU and allows for the calculation for the probability of death. The goal of our study is to evaluate the APACHE-II score in predicting mortality of patients admitted to the ICU with acute GIB. After approval from our Institutional Review Board was obtained, patients
S-575
AGA Abstracts
AGA Abstracts
statistical difference was found in patients who underwent screening (AM-1198(65.1%), PM750(65.3%)) and surveillance (AM-643(34.9%), PM-432(36.5%)) colonoscopies. Quality of bowel preparation did not show statistically significant difference between the groups. Cecal intubation rate was 96.7% in the AM group and 96.2% in the PM group. Polyp detection rate was significant in the PM group (59.7% in AM vs 76.7% in PM; p-0.003). Adenoma detection rate in the two groups showed no statistical significant difference (22.9% in AM vs 26.3% in PM; p-0.103). Location of the polyps in two groups did not show statistical significant difference (p-0.056). Significant CRN were detected in 29% of the patients in the AM group and 32.5% in the PM group (p-0.207). Carcinoma was detected in 10(0.5%) patients in the AM and 8(0.7%) in the PM group. Conclusion:Our study showed that adenoma detection rates were not inferior as the day progresses. Bowel preparation quality was also independent of the time of the day. Higher polyp detection rate in PM group was likely due to the variation in the performance and the experience of the endoscopist. We conclude that the shift schedule does not show a decrease in the ADR as the day progresses as seen in the other studies. Bowel Preparation (p-0.746)
Location of Polyps (p-0.56)
Mo1024 Endoscopic Cyanoacrylate Injection for the Treatment of Gastric Varices: Experience of a Single US Center Murad Abu Rajab, Adrian N. Holm, Rami El-Abiad, Henning Gerke Background:Gastric variceal hemorrhage has a high mortality. Endoscopic cyanoacrylate glue injection (CGI) is successfully used in other countries; however there is limited experience with this method in the US because it is not currently approved by the Food and Drug Administration. Objectives:To assess the safety and efficacy of CGI for treating gastric varices. Patients and Methods:A retrospective chart review of patients who were treated with CGI for gastric varices at a US tertiary care center between 6/2005 and 8/2011. Assessed outcomes included primary hemostasis, recurrent bleeding during hospitalization, rebleeding during follow-up, and complications. Results:Forty-Six patients with gastric varices were included in the study (32 males; mean age 60.6±12.5 years). The underlying cause of gastric varices was cirrhosis in 31, idiopathic portal hypertension in 2, splenic vein thrombosis in 6 and other/unknown etiology in 7 patients.. Concomitant esophageal varices were present in 30 patients. CGI was performed for acute bleeding in 44 patients and for bleeding prophylaxis in 2 patients. CGI was performed with N-butyl-2-cyanoacrylate (n=40), 2-octanyl-cyanoacrylate (n=5) or both (n=1), and N-butyl-2-cyanoacrylate was injected undiluted (n=19), diluted with ethiodized oil (n=21) or both (n=1). The average injected volume during the index endoscopy was 4.5ml±2.7. One (n=4) or more (n=3) additional CGI sessions were performed in 7 patients. Actively bleeding gastric varices during index endoscopy were found in 7/46 patients (15%) and initial hemostasis was achieved in all. Early rebleeding from gastric varices during hospitalization occurred in one patient (2%). Hemostasis was achieved with repeat CGI but the patient died during hospitalization from sepsis. Immediate complications of CGI included ischemic stroke in 2 patients (4%) without residual deficit on follow up, and asymptomatic portal vein cyanoacrylate emboli in one patient (2%). Thirty-three patients had a median follow up beyond initial hospitalization of 14 months (range 1-73). Additional treatments in these patients included esophageal variceal banding in 18, TIPS in 2, splenectomy in 2 and splenic artery embolization in one. In 30/33 (91%) patients no gastric variceal bleeding occurred during follow up. Three patients had rebleeding from gastric varices that was successfully treated with CGI. Four patients had transient mucosal bleeding from the cyanoacrylate injection site despite fully obliterated gastric varices. No intervention was necessary. Three patients had bleeding from esophageal varices treated with band ligation. Conclusion: Endoscopic treatment of bleeding gastric varices using cyanoacrylate glue injection is effective. Serious complications are infrequent. Objectives for future research should include means to further reduce the risk of embolic events.
Mo1022 PEG-3350 for Colon Preparation in Children: Head to Head Comparison Between 2 and 4 Days Protocols Rotem Elitsur, Lisa Butcher, Vicki A. Lund, Yoram Elitsur Preparation of the colon for colonoscopy in children is a difficult task due to a poor compliance. In a previous study we reported an adequate colon preparation in >92% of children using PEG-3350 protocol for 4 days (Safder 2008). In recent publication, PEG3350 protocol for 2 days reached comparable results (Phatak 2011). Aim: To compared between 2 days and 4 days colon preparation protocols. Methods: Children scheduled for colonoscopy for various medical reasons were prospectively and randomly assigned for the 2 different protocols. Protocol A included 4 days PEG-3350 (1.5g/Kg) treatment, and Protocol B included 2 days PEG-3350 (2.0g/Kg) treatment with a daily 5 mg tablet of Bisacodyl. In both protocols, the patients filled a questionnaire that included the number of stools/day, consistency of stools/day and side effects (n/v, abdominal pain). Colon preparation was graded from 1 to 5 (1- unprepared, 5- excellent/crystal clear) as previously described (Safder 2008). Grade ≥4 was defined as an adequate colon preparation. At the end of the procedure, the colon preparation was independently assessed and graded by the endoscopy nurse and the physician. Results: A total of 54 pts participated of whom 31 pts included in protocol A and 23 pts in protocol B. Seven children violated the protocol (violation of instructions, dose of PEG-3350, etc.), and were excluded from final analysis. Overall, in both protocols, a similar rate of adequate colon preparation (≥4) was achieved. Side effects (Abd. pain, V) were minimal and comparable in both groups. An excellent agreement in colon grading was achieved between the physician and the endoscopy nurse (Pearson correlation >0.95). Results are described in Table 1. Conclusion: Bowel preparation with PEG-3350 for 2 days is as good as for 4 days protocol. Two days protocol has the advantage of being shorter and easier for children. Colon preparation and protocols
Mo1025 Risk of Perforation Following Endoscopic Colorectal Stenting is Associated With use of Bevacizumab Glen A. Doherty, Ciaran Judge, Blathnaid Nolan, Dara Kavanagh, Diarmuid P. O'Donoghue, John Hyland, Des C. Winter, Hugh Mulcahy Background. Endoscopic colorectal stenting is considered an effective means of relieving malignant colorectal obstruction, either as part of a palliative care pathway or as a bridge to definitive surgical therapy. Concerns have recently been raised about the safety of colorectal stenting, with high rates of perforation reported in some clinical trials. Aims: To assess the safety and efficacy of endoscopic stenting for neoplastic colonic obstruction. Methods. Patients assessed by endoscopy with a view to colorectal stenting at a single centre were identified by searches of electronic radiology and endoscopy reporting databases. Electronic and clinical records were reviewed and cross-referenced with a prospectively maintained database of patients with colorectal cancer. Results. 112 procedures were performed in 102 patients with a view to stent insertion, with a decision made not to insert a stent in 17 cases (most due to insufficient luminal narrowing). 90 stents were successfully deployed in 95 procedures where there was intent to place a stent (technical success rate 95%). 67 stents were placed with palliative intent and 23 stents as a bridge to subsequent surgery. In the palliative stenting group surgery was avoided in 68% with median interval to death or last follow up of 6.9 months (IQR 2.1-10.5 months). 10 patients required repeat stenting at a median interval of 162 days (IQR 109-206 days). Clinical perforation subsequent to stent placement was described in 9/90 procedures (perforation rate 10%) with the rate of perforation higher in patients who received the monclonal antibody to VEGF bevacizumab; 5/31(16.1%) in
* At the last day of protocol. ** Grade ≥4.0 is adequate colon preparation. Mo1023 Evaluation of the APACHE-II Score in Predicting Mortality in Patients Admitted to the ICU With Acute GI Bleeding Fedele DePalma, Patricia Henry, Philip Elbaum, David Gerber Several scores have been designed to triage patients with acute gastrointestinal bleeding such as the Glasgow-Blatchford Score and Rockall Risk Scoring System. No scoring system has been developed to estimate the mortality of patients with acute gastrointestinal bleeding (GIB) admitted to the intensive care unit (ICU). The APACHE-II score has been used for over 25 years to provide a general measure of severity of disease for patients admitted to the ICU and allows for the calculation for the probability of death. The goal of our study is to evaluate the APACHE-II score in predicting mortality of patients admitted to the ICU with acute GIB. After approval from our Institutional Review Board was obtained, patients
S-575
AGA Abstracts
AGA Abstracts
statistical difference was found in patients who underwent screening (AM-1198(65.1%), PM750(65.3%)) and surveillance (AM-643(34.9%), PM-432(36.5%)) colonoscopies. Quality of bowel preparation did not show statistically significant difference between the groups. Cecal intubation rate was 96.7% in the AM group and 96.2% in the PM group. Polyp detection rate was significant in the PM group (59.7% in AM vs 76.7% in PM; p-0.003). Adenoma detection rate in the two groups showed no statistical significant difference (22.9% in AM vs 26.3% in PM; p-0.103). Location of the polyps in two groups did not show statistical significant difference (p-0.056). Significant CRN were detected in 29% of the patients in the AM group and 32.5% in the PM group (p-0.207). Carcinoma was detected in 10(0.5%) patients in the AM and 8(0.7%) in the PM group. Conclusion:Our study showed that adenoma detection rates were not inferior as the day progresses. Bowel preparation quality was also independent of the time of the day. Higher polyp detection rate in PM group was likely due to the variation in the performance and the experience of the endoscopist. We conclude that the shift schedule does not show a decrease in the ADR as the day progresses as seen in the other studies. Bowel Preparation (p-0.746)